Proper Billing and Coding of Laboratory Services: A Survey of CPT and HCPCS Codes

Proper Billing and Coding of Laboratory Services: A Survey of CPT and HCPCS Codes Jennifer Bolen, JD

Disclosures  Ms. Bolen serves as a consultant on a variety of issues, including billing and coding for clinical laboratory services, for the following clinical laboratories: – Alere Toxicology, AFTS Laboratories, Andor Laboratories, Peace Health Laboratories, Physicians Pharmaceutical Corp. , ReCept Pharmacy – Numerous individual physician-owned and CLIA-waived, CLIA-certified laboratories.

 Grant/Research Support – Alere Toxicology, AFTS Laboratories

 Honoraria – ReCept

 Speaker’s Bureau – Alere Toxicology, AFTS Laboratories, Andor Laboratories, Physicians Pharmaceutical Corp. , ReCept Pharmacy

Learning Objectives  After attending this lecture, participants will be able to: – Describe the proper CPT and HCPCS codes for qualitative drug screening under CLIA-Waived or Moderate Certificates – Cite proper CPT and HCPCS codes for qualitative drug screening for CLIA High Complexity tests – List basic codes applicable to Quantitative testing through an independent clinical laboratory – Recognize inappropriate coding of point-of-care drug screening and other coding hot topics tied to use of analyzers – Locate the Clinical Laboratory Center hosted by CMS

Laboratory Coding Overview  Medicare addresses clinical laboratory tests using a “fee schedule” – Clinical Laboratory Fee Schedule May be found at: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ClinicalLabFeeSched/index.html

• Establishes what will be paid for those tests • Establishes who may bill for those tests • Provides payment in full with no deductible or coinsurance payable by the Medicare beneficiary

 Variation in application of payment principles

– Medicare contractors (MACs), fiscal intermediaries, or carriers may apply payment principles with some variation in methods – Medicare payment principles are uniform – NOTE: Medicaid policies vary from state-to-state – NOTE: No uniformity among payment policies used by commercial or private insurers – Billing/coding staff should pay careful attention to state laws when billing Medicaid and Commercial/Private Insurers, especially when analyzing direct billing requirements/prohibitions

Coding Basics: CPT Codes Current Procedural Terminology owned by the American Medical Association –CPT creates a uniform language that allows for communication among healthcare professionals, patients, and health insurance companies –The use of CPT does not guarantee payment by a third-party

CPT Code Sections Tied to Drug Testing  Drugs of Abuse Testing – Qualitative – CPT 80100-80102, and 80104 (Note: 80102 is the Confirmation Code and requires a different test method than the original screen; and 80104 is out of sequence)  Therapeutic Drug Testing – CPT 80150-80299 (Quantitative Testing Only)  Chemistry – CPT 8200-84999 (Quantitative UNLESS Otherwise Specified)

Healthcare Common Procedural Coding System (HCPCS) Codes Level I

Level II

 CPT Codes universally used by Medicare, Medicaid, and commercial payors

 Distributed by CMS and begin with letters A through V, followed by numbers  Regularly updated  Grouped by type of service or supply

HCPCS Level II “G” Codes & Application to Clinical Laboratory Services  “G” Codes refer to procedures/professional services that are temporary in nature – Usually temporary because CMS is in the process of resolving coding issues (descriptors, etc.) that may also relate to existing or the need for new CPT codes or other action

 G0434 and G0431 are both HCPCS temporary codes – If a “G” code has a counterpart in CPT, Medicare will often require the “G” code – Examples: – Medicare requires use of HCPCS G0434 instead of CPT 80104.

– Medicare also requires use of G0431 and has deleted CPT 80101 from the CLFS

Coding Basics 1. All claims should include the CPT or HCPCS code that accurately describes the service that was ordered and performed 2. The National Correct Coding Initiative Policy (NCCI) requires that the code that describes the procedure “to the greatest specificity possible� should be used 3. If the services that have been provided are described by a single code, that code should be used rather than multiple codes

Coding Basics (cont’d) 4. Laboratories cannot change the physician’s order without the physician’s express consent 5. Laboratories routinely offer customized test panels to physicians.

OIG requires that clinical laboratories tell physicians that they should not order customized panels UNLESS there is medical necessity for each test within the panel – OIG has stated that customized test panels and profiles contribute to unbundling billing schemes and should be used with caution and understanding of medical necessity guidelines – Key Resource: • OIG Compliance Guidance, 63 Fed. Reg. 45076, 45079 (Aug. 24, 1998)

Use of Modifiers  Medicare permits the use of certain modifiers to claim payment for clinical laboratory services – The QW Modifier – designates a laboratory test that is considered CLIA-waived – Modifier 90 – used to submit a Medicare claim for payment for a test performed by another laboratory as a result of a lab-to-lab referral.

Must meet specific requirements to use this modifier – Modifier 91 – used to report the performance of the same test more than once for a patient on the same day. Specific requirements here – Others (Modifier 59)

Coding Basics  ICD-9 Codes (ICD-10) – a coding system used to translate medical terminology for diseases and procedures into numeric codes – Medicare relies heavily on the diagnosis code included on a claim for payment in determining whether a clinical laboratory test is medically necessary and thus covered by Medicare – Diagnosis coding is thus critical when seeking reimbursement for clinical laboratory testing

 A variety of ICD-9 codes for supporting medical necessity of qualitative drug screening; some may be directed by the payor through Local Coverage Determinations and Medical Policies

Medical Necessity Basics  Medical Necessity for Drugs of Abuse Testing is covered in MDL-02  Generally, the treating physician determines the tests that are medically indicated to diagnose or treat a patient

– The physician is the one who orders the clinical laboratory tests to be performed by a laboratory – The laboratory, however, bears the loss when its claim for payment is denied for lack of medical necessity – The Office of Inspector General (OIG) looks to clinical laboratories to ensure that Medicare payment claims are submitted only for medically necessary testing – OIG expects clinical laboratories to tell physicians that only claims for medically necessary services will be paid – OIG encourages clinical laboratories to “take all reasonable steps to ensure that it is not submitting claims for services that are not covered, reasonable and necessary.” OIG Compliance Guidance, 63 Fed. Reg. 45076, 45079 (Aug. 24, 1998)

Medical Necessity Basics (cont’d) Claims for Medicare payment for a service that is not medically necessary may be false claims

Coding & Relation to Fraud and Abuse Laws  Codes are used for billing  Correct reimbursement is tied to proper coding  Some coding errors are inadvertent and true mistakes  Knowing and intentional utilization of incorrect codes with the specific intent to obtain greater reimbursement can bring coding into the purview of federal fraud investigations  Patterns of coding “errors” demonstrate recklessness and may also result in fraud investigation

Laws Applicable to Coding Violations  The Civil Monetary Penalties Law (CMPL)  Criminal Statutes  The False Claims Act  The Anti-kickback Statute  The Stark Law  Various state laws under more general fraud statutes  Other

Legal Issues in Laboratory Coding  Scrutiny of claims for payment for laboratory services common  Most common types of fraud involve false claims, including: – billing for services not performed – billing for services not ordered – billing for services not needed – up-coding – Unbundling – duplicate billing – falsifying diagnoses

Important Resources  AMA CPT 2012  CMS Coverage Database: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx  Various Commercial Payor Websites  Clinical Laboratory Center (CMS): http://www.cms.gov/Center/Provider-Type/Clinical-Labs-Center.html • OIG Compliance Guidance for Clinical Laboratories: 63 Fed. Reg. 45076, 45079 (Aug. 24, 1998).

Proper Use Of CPT 80101 Qualitative Drug Screening, Single Drug Class, Non-Medicare

CPT 80101  80101 Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class.

DELETED FROM CLFS. Do not use this code for Medicare payment claims  Used to report drug screen testing via a single drug class method to a non-Medicare payor SUBJECT TO THAT PAYOR’S RULES  NOTE: It is NOT appropriate to use this CPT code when you perform a procedure with a multiple drug class method, i.e. cup or dipstick that tests for 2 or more drug class/drugs  NOTE: For qualitative analysis by multiplexed screening kit for multiple drugs or drug classes, use CPT 80104  CAUTION: Use of this code to report multiple dips that could be performed together and coded under CPT 80104, may be perceived as inappropriate and result in overpayment requests and/or fraud investigation for unbundling or up-coding

Proper Use of CPT G0434QW and G0434 Qualitative Drug Screening

Current Coding for Medicare G0431

G0434

Qualitative Drug Screen, Multiple Drug Classes

Qualitative Drug Screen, Any Number of Drug Classes, Non-Chromatographic Method

High Complexity

CLIA-Waived or Moderate

Per Patient Encounter

Per Patient Encounter

G0431 x 1 if High Complexity

G0434QW x 1 if CLIA-Waived G0434 x 1 if CLIA-Moderate

Proper Use of HCPCS G0431 G0431 Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter DO NOT USE QW Modifier. DO NOT USE IF CLIA WAIVED OR MODERATE NOTE: Old (2010) descriptor: single drug class method (e.g., immunoassay, enzyme assay,) each drug class NOTE: Limited to a maximum of 1 unit of service!

2012 “G” Codes for Clinical Laboratory Testing (Drug Screens)  G0434 Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter

– Maximum number of units per date of service: 1 – 2012 reimbursement is $20.60 nationally – 2012 it is appropriate to use the QW Modifier if CLIA-Waived and reporting G0434 – Some Medicare contractors have erroneously denied UDS testing when G0434 reported with QW modifier, so you should APPEAL the denial!

 2012 Medicare Clinical Lab Fee Schedule http://www.cms.gov/ClinicalLabFeeSched/

SE1105 – Published by CMS in 2/2011

CMS SE 1105 (Feb. 2011)  G0434: will be used to report very simple testing methods, such as dipsticks, cups, cassettes, and cards, that are interpreted visually, with the assistance of a scanner, or are read utilizing a moderately complex reader device outside the instrumented laboratory setting (i.e., non-instrumented devices) – Includes qualitative drug screen tests that are waived under CLIA as well as dipsticks, cups, cards, cassettes, etc that are not CLIA waived

 Labs with a CLIA certificate of waiver shall bill using the QW modifier; labs with a CLIA certificate of compliance or accreditation do not append the QW modifier to claim lines – Only one unit of service for code G0434 can be billed per patient encounter regardless of the number of drug classes tested and irrespective of the use or presence of the QW modifier on the claim lines

http://www.cms.gov/MLNMattersArticles/Downloads/SE1105.pdf

CMS SE 1105 (cont’d)  G0431: will be used to report more complex testing methods, such as multichannel chemistry analyzers, where a more complex instrumented device is required to perform some or all of the screening tests for the patient. This code may only be reported if the drug screen test(s) is classified as CLIA high complexity test(s); may only be reported when tests are performed using instrumented systems (i.e., durable systems capable of withstanding repeated use)  CLIA waived tests and comparable non-waived tests may not be reported under test code G0431; they must be reported under test code G0434QW  CLIA moderate complexity tests should be reported under test code G0434 with one (1) Unit of Service (UOS)  May only be reported once per patient encounter  Must not append the QW modifier to claim lines

CMS Transmittal 2155 (2/11/11) “The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare & Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA certificate level For 2011, the code G0430 has been deleted and G0434 is its replacement. Therefore, the code G0434QW replaces G0430QW in the attached list The Medicare contractor shall permit the use of code G0434QW for claims submitted by facilities with a valid, current CLIA certificate of waiver with dates of service on or after January 1, 2011�

https://www.cms.gov/transmittals/downloads/R2155CP.pdf

Proper Use of CPT 80104 Qualitative Drug Screen – Non-Medicare

CPT 80104  80104 Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure  Description of Procedure: In the evaluation of a patient for an opioid trial, the clinician performed a rapid urine toxicology screen using a multidrug screening device(cup, dipsticks, test card kit) that simultaneously screens for six different prescription drug and substance classes. The screen was negative for illicit drug classes and positive (as expected) for opioids  Code: CPT 80104 x 1. This code is used to report a qualitative analysis drug screen for 2-15 drugs or drug classes by a multiplexed method, (e.g. multidrug screening kit - a cup or dipstick that tests for > 2 drug classes  NOTE: Regardless of the number of assays or drug classes tested, the maximum unit of service for this code is “1”

NOTE: Do not use this code on Medicare claims

BCBS and Use of CPT 80104 May 2011

BCBS of TN and Use of CPT 80104 May 2011

Can You Perform Both A Screen And A Confirmation In The Point Of Care Setting?

Can You Use Of G0434 (Or 80104) And 80102?

SHORT ANSWER

NO

Explanation  A confirmation test, by definition, must be performed by a second test method, not the same test method used to perform the original screen  Different test method DOES NOT mean a cup to an analyzer, because both test methods used are immunoassay or enzyme immunoassay  Different test method WOULD INCLUDE immunoassay (1st test method) for the screen and then chromatographic (GC or LC/MS) (2nd test method) for the confirmation (regardless of whether 80102 or a quantitative result)  SOURCES: ALL LCD and DRAFT LCD for Qualitative Drug Screening (2012). Examples: DL32450 (WPS)

Can I Use Quantitative Codes If I Test With A Chemistry Analyzer?

Another VERY HOT TOPIC

http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%2011%20Part%20B~Browse%20b y%20Topic~Drugs%20Biologicals~8Q2LHW8528?open&navmenu=Browse^by^Topic||||

What Happens When An Outside Laboratory Does The Testing And Coding?

General Information on Confirmation and Quantitative Test Coding

Discussion & Summary Where Will We Be In 2013?